The invention relates to an intradiscal lesioning apparatus for treating intervertebral disc disorders, such as localized tears or fissures in the annulus fibrosus, localized disc herniations, and circumferential bulging of discs.
Lower back injuries and chronic back pain are a major health problem resulting not only in a debilitating condition for the patient, but consuming a large proportion of funds allocated for health care, social assistance and disability programs. However, there is no consensus among medical researchers on the mechanism of the disorder despite extensive experimentation and clinical testing on the subject. Disc abnormalities may result from trauma, repetitive use in the workplace for example, metabolic disorders or aging.
Each intervertebral disc is composed of a central, gel-like nucleus pulposus surrounded by a tough fibrous semielastic annulus fibrosus. Common disorders include localized tears or fissures in the annulus fibrosus; localized disc herniations with contained or escaped extrusions of the nucleus pulposus; and chronic circumferential bulging of discs. For most patients, however, a well-defined abnormality cannot be found to solely explain the cause of the low back pain, making treatment and pain management very difficult. Isolated cases where a specific anatomic disorder can be diagnosed are the exception. Regrettably, most patients are merely treated symptomatically to reduce pain, rather than to eliminate the root cause of the condition.
The intervertebral discs form about one-quarter the length of the vertebral column in a healthy adult human. Discs are thickest in the cervical and lumbar regions, where the movements of the vertebral column are greatest. With age the vertebral column, including the intervertebral discs, undergo various morphological and biochemical changes such as dehydration of the discs and concaving vertebral bodies. As a result, the size and configuration of the disc components vary considerably from person to person.
The annulus fibrosus is composed of concentric layers of fibrocartilage, in which the collagen fibers are arranged in parallel strands running obliquely between vertebral bodies. The inclination is reversed in alternate layers thereby crossing over each other obliquely. In children and adolescents, the nucleus pulposus is an amorphous colloidal mass of gelatinous material containing glycosaminoglycans, collagen fibrils, mineral salt, water and cellular elements. The nucleus pulposus is normally under pressure and is contained within an ovoid cavity formed laterally by the annulus fibrosus and bounded by thin plates of hyaline cartilage covering the adjacent vertebrae. The annulus fibrosus is thinner nearer to the posterior than to the anterior margin of the disc, and many disc ruptures occur in the posterior region thereby exerting pressure on the adjacent nerve fibers.
Increasingly however, evidence suggests that the source of back pain in many patients are nerves within the degenerated disc itself, rather than the exertion of pressure on adjacent spinal nerves by a damaged disc. For example, as documented by Jonathan C. Houpt, B A, Edison S. Conner, M D, and Eric W. McFarland in xe2x80x9cExperimental Study of Temperature Distributions and Thermal Transport During Radiofrequency Current Therapy of the Intervertebral Discxe2x80x9d, Spine. 1996;21(15), 1808-1813, afferent innervation of the outer half of the annulus fibrosus has been established whereas the nucleus pulposus contains no nerves or blood vessels. Pain response has been widely reported in response to specific stimulation of the outer layers of the annulus fibrosus. In another study documented by A. J. Freemont, xe2x80x9cNerve ingrowth into diseased intervertebral disc in chronic back painxe2x80x9d, The Lancet. 1997; 350, 178-181, nociceptive nerves were found ingrown deeper into the disc, as far as the nucleus pulposus, in association with disc degeneration.
Where patients are diagnosed with clear discogenic pain (i.e. pain originating from a disc), complete surgical removal of the intervertebral disc and fusion of the adjacent vertebrae is often carried out with success rates over 80% in measurable pain reduction after surgery. Such major surgical procedures are invasive, expensive and involve significant risk. To alleviate some of the disadvantages of diskectomy, U.S. Pat. No. 5,201,729 to Hertzmann et al describes a percutaneous method of diskectomy.
Due to the pain reduction success of surgical diskectomy, less drastic means of denervating rather than surgically removing the disc are of significant interest. Denervating the disc is less invasive, less costly, simpler to administer and does not require the fusing of adjacent vertebrae thereby better preserving the patient""s freedom of movement.
To destroy nerve cells in the annulus fibrosus, the prior art includes probes that emit various forms of energy from within the nucleus pulposus such as, radio frequency electric current, microwave or thermal energy. It appears that the surface of the disc is devoid of temperature sensing neurological structures, probably since the disc is at core body temperature, and only mechanical and chemical stimulus-sensing nociceptors exist in the annulus fibrosus.
U.S. Pat. No. 5,433,739 to Sluijter et al describes a method of relieving back pain through percutaneous insertion of a needle or electrode into the intervertebral disc under fluoroscopy or other imaging control. Radio frequency electrodes of the same type are commonly used in neurosurgery, anesthesiology and cardiology to lesion neural tissue including an insulated shaft with an exposed tip conducting radio frequency current. A second dispersive electrode with large surface area is placed elsewhere on the patient""s body to complete the circuit. The intensity of radio frequency current at the exposed tip causes heating of the adjacent tissue and when the temperature increases sufficiently, the neural tissue is coagulated. The mechanism is direct interruption of the nerves by formation of a lesion and thus the transmissions of pain signals are blocked.
It is well known to those skilled in the art that percutaneous access to the disc is by placing a needle or tube into the disc from the posterior lateral approach, but the limited access does not allow much room to manoeuvre. Once the tube pierces the tough annulus fibrosus, the tube is fixed and has very little freedom of movement. Thus, with a simple needle or electrode, access to only small portions of the central and anterior nucleus pulposus is available.
To permit percutaneous access to the posterior half of the nucleus or to the posterior wall of the disc, U.S. Pat. Nos. 6,007,570; 6,073,051; 6,122,549 and 6,126,682 to Sharkey et al describe a flexible heating element that is inserted into the nucleus pulposus through a hollow tube that has been pierced through the annulus fibrosus. The flexible heating element has sufficient rigidity to be advanced longitudinally under force through the nucleus pulposus while having flexibility to be compliant to the inner wall of the annulus fibrosus. The heating element is guided by sliding contact with the inner wall and ideally should not puncture or damage the annulus fibrosus during positioning.
The shape, size and configuration of the nucleus pulposus may vary considerably and obstacles such as a radial fissure or a fibrous lump, commonly existing in degenerated discs, may impede sliding contact of the heating element. As a person ages, the border between the nucleus pulposus and the annulus fibrosus becomes less distinguished, beginning when a person is about 30 years old. The transition zone is made of both fibrous material of the annulus fibrosus and gelatinous material of the nucleus pulposus. However, the Sharkey heating element relies on sliding contact with the inner wall of the annulus fibrosus to guide it into position and to bend the element into a configuration that closely engages the inner wall of the annulus fibrosus. As a result, the accuracy with which the Sharkey heating element can be placed is limited. Placement may be impeded by damage to the inner wall, ruptures or lack of wall rigidity.
The efficacy of the heat induced denervation procedure appears to depend largely on the accuracy with which energy is applied to the neural tissue within the outer portion of the annulus fibrosus. In Jonathan C. Houpt, B A, Edison S. Conner, M D, and Eric W. McFarland in xe2x80x9cExperimental Study of Temperature Distributions and Thermal Transport During Radiofrequency Current Therapy of the Intervertebral Discxe2x80x9d, Spine. 1996;21(15), 1808-1813, temperature distribution inside an intervertebral disc and the thermal diffusivity was investigated experimentally. In particular, the temperatures reached in the outer annulus were of interest since this is the area of the disc known to be innervated. The objective of the experiment was to test the hypothesis that back pain relief was due to heat conducting from the centre of the disc to the outer annulus that coagulated the neural tissue or afferent nociceptors therein.
It was found that, under the experimental parameters, clinical intradiscal heating profiles in use did not produce sufficient temperature increases to achieve denervation, and other explanations for the perceived back pain relief were suggested. Heat alone does not appear to explain the clinical results. Nevertheless, the clinical evidence does suggest that there is a clear benefit for many patients who undergo intradiscal treatment, despite the lack of understanding as to the precise cause or mechanism for such improvement in pain relief.
Therefore delivery of various forms of energy to the nucleus pulposus to relieve back pain, preferably immediately adjacent the externally innervated annulus fibrosus, shows promise and will continue to be investigated in the future.
It is an object of the present invention to provide a device that delivers sufficient energy to the annulus fibrosus to achieve denervation and/or modification of collagen fibrils with predicable accuracy.
It is a further objective of the present invention to provide a device that can be accurately positioned, within any portion of the nucleus pulposus of any lumbar intervertebral disc having variable shape, in order to deliver energy to any selected area of the annulus fibrosus.
It is a further object of the invention to provide a device that can adopt a variety of different configurations within the nucleus pulposus to deliver targeted energy to any selected area of the annulus fibrosus.
It is a further object of the invention to provide a heating or energy delivering element that can be positioned in close proximity to the inner wall of the annulus fibrosus, but that does not entirely depend on physical contact with the inner wall of the annulus fibrosus to enable the element to adopt a selected configuration.
Further objects of the invention will be apparent from review of the disclosure, drawings and description of the invention below.
The invention provides an intradiscal lesioning device for percutaneous treatment of a patient""s intervertebral disc that has a pathological condition that causes discogenic pain. An elongate introducer having a longitudinal hollow bore is surgically inserted from the patient""s skin to extend through the annulus fibrosus thereby providing external surgical access to the nucleus pulposus through the introducer bore. An elongate probe slides through and flexibly conforms to the bore when longitudinally inserted through the bore of the introducer. The distal portion of the probe is capable of conforming to the bore in a longitudinally slidably confined configuration and being deployed into a predetermined configuration when released within the nucleus pulposus in which the distal portion forms at least one loop of a dimension able to remain within the nucleus pulposus without contacting the inner wall. The distal portion houses lesioning devices for emitting energy in the disc when the distal portion is in the deployed configuration. Examples of suitable energy sources include: thermal energy; radio frequency electric current; microwave emission; ultrasound emission; radioactive emission; and optical emission. The deployed preform shape includes: a hook; a spiral coil; a helical coil; a cylindrical coil; a flat plate; an arcuate sheet; an elongate tape; a closed loop; an open loop; and a partial spherical basket.
As well, active actuators may be included for progressively developing the trajectory of the distal portion in three-dimensional space, as the distal portion is longitudinally slidably released from the outer end of the introducer into the nucleus pulposus. For example, mechanical activators can include: a cable extending from the distal end through the introducer; hydraulic actuators within the distal end; piezoelectric actuators within the distal end; and solenoid actuators within the distal end.
Therefore, the system comprises an introducer, a probe that enters the nucleus pulposus via the introducer, an intradiscal distal portion of the probe that resiliently rebounds to a shape that will give close access to the interior wall of the annulus fibrosus, an energy emission device within the distal portion that is supplied by a power source, temperature sensors and a monitoring system that measures temperature and controls the supply of energy.
The introducer is an insertional apparatus that provides proximity to the intervertebral disc. The outer end of the introducer may be sharply beveled to facilitate percutaneous entry and passage through various tissues to reach the intervertebral disc and penetrate the tough, cartilaginous annulus fibrosus. The introducer may also have a stopper or handle on the inner end. In its simplest form, the introducer can consist of a hollow needle-like device, optionally fitted with an internal removable obturator or trocar to prevent clogging during initial insertion. The hollow tube acts as a guide for introducing the instrumentation probe. More complex variations can include one or more temperature transducers, such as thermocouples or thermistors, at various locations along the length of the introducer with exposure to the outer surface of the probe for the purpose of measuring or monitoring the temperature at various locations within the intervertebral disc and surrounding tissue.
For one embodiment, the introducer cross-sectional size is sufficient to house the operational components of the probe while being as small as possible to be minimally invasive. For example, the introducer may be of needle gauge in the range of 18 GA to 15 GA with an outer diameter in the range of 1.283 mm to 1.842 mm and an inner diameter in the range of 0.75 mm to 1.61 mm. The length of the tube is sufficient to reach the intradiscal space from the exterior of a large human posterior-laterally at an angle of 25 to 50xc2x0 lateral of the midsagittal plane, namely, in the range of 7 cm to 20 cm. The part of the introducer that comes into contact with any internal tissue of the patient is made of biocompatible and sterilizeable material, such as surgical steel. The introducer has sufficient strength to sustain the action of piercing through tissues, notably the cartilaginous annulus fibrosus, to access the nucleus pulposus, various movements within the tissues such as moderate twisting and wiggling, and removal from the tissues.
The probe consists of a proximal end connected to a distal end. The proximal end preferably includes an extension shaft that is stiff and strong enough to allow the user to apply longitudinal force to push the distal end out of the distal end of the introducer and into the nucleus pulposus. The extension shaft can be a tube of 304 stainless steel, optionally with a sheath covering. The outside diameter of the probe extension shaft will range from 0.7 mm to 1.5 mm, the wall thickness will range from 0.05 mm to 0.15 mm and the inside diameter will range from 0.4 mm to 1.4 mm. The length of the extension shaft will be approximately the same length as the introducer, in the range of 7 to 20 cm. Wires to connect the energy source to the delivery mechanism and to connect the temperature sensors in the probe to the monitoring system can pass through the extension shaft.
The distal end of the probe, or intradiscal portion, will be flexible enough to take a shape that allows close proximity with the inner wall of the annulus fibrosus. The probe distal portion passively and resiliently rebounds to a preform shape to actively navigate through the nucleus pulposus. The distal portion shape includes but is not limited to a shape memory alloy loop, coil, basket, or manually extended loop and can be navigated using electronic, mechanical or hydraulic means. The distal portion will also carry the components that supply thermal energy, temperature sensors or other means of denervating the annulus fibrosus with energy emissions under controlled conditions.
Therefore it will be appreciated that the invention provides significant advantages over the prior art specifically U.S. Pat. Nos. 5,980,504 and 6,007,570 to Sharkey et al. The flexible heating element of the Sharkey patents is dependent on engaging inner wall of the annulus fibrosus and is guided by sliding contact with the inner wall to form the curved shape within the nucleus pulposus. Since many damaged portions of an intervertebral disc require treatment of the posterior section of the disc, reliance on contact with the inner wall significantly limits the ability of the flexible Sharkey heating element to engage the full interior wall of the disc.
In contrast, the present invention provides several pre-form shapes and actively navigated shapes that can engage any selected target portion or the entire posterior lateral or anterior portions of the inner wall of the annulus fibrosus.
A method for percutaneous treatment of a patient""s intervertebral disc is also provided. The method comprises surgically inserting and placing an elongate introducer, comprising a tube having an inner end, an outer end and a longitudinal hollow bore extending therebetween through the annulus fibrosus thereby providing external surgical access to the nucleus pulposus through the bore; inserting an elongate probe having a proximal portion and a distal portion into the bore, the probe slidably engaging and flexibly conforming to the bore when longitudinally inserted through the bore from the inner end to the outer end of the introducer; deploying a distal portion of the probe into a configuration within the nucleus pulposus in which the distal portion forms at least one loop of a dimension able to remain within the nucleus pulposus without depending on contact with the inner wall; connecting the probe to an energy source; and emitting energy from the energy source at the distal portion into the disc.
Further advantages of the invention will be apparent from the following detailed description and accompanying drawings.